Healthcare Provider Details

I. General information

NPI: 1578126850
Provider Name (Legal Business Name): DONALD ADAM MICHAEL RUDOLPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 E MAIN ST
BOZEMAN MT
59715-3850
US

IV. Provider business mailing address

1315 E MAIN ST
BOZEMAN MT
59715-3850
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-2477
  • Fax:
Mailing address:
  • Phone: 406-587-2477
  • Fax: 406-587-9526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: